AJOB Empirical Bioethics

VOL. 9 No. 2 | June 2018

07/26/2015

I was invited to write a review of the book, Being Mortal, by Atul Gawande recently. While not a Christian book, it addresses end of life issues of interest to all involved with bioethics. This is the second half of the review, the first of which can be found here.

Nearly half of Gawande’s book reflects on final things, on letting go of life in the face of the limits of mortality. In this way, it supplements the excellent book by another physician, Ira Byock, called Dying Well: Peace and Possibilities at the End of Life. Through stories of real people, including his patients and even his own dying father, Gawande offers a harsh critique of the role modern physicians play as the chance for cure slips away with terminal diseases. That so many people die in a hospital setting, undergoing treatments inconsistent with their deepest convictions and in conflict with their ultimate goals, he finds disturbing. True, he is not at all unique in this assessment. He is also not unique in the celebration of the value of palliative and hospice care in decreasing the numbers of patients who face the end of their lives in hospitals, and who actually find the length and quality of their lives substantially improved over those who do not receive such care. Where Gawande is especially effective is in the way he can tell a story…one that links the crux of the patient’s own narrative with the medical realities (and innate struggle of the physician and the caregiving team) in the cases he uses for illustration. He lays bare the error of many within modern medicine who have transitioned from a paternalistic model that would tell patients what is best for them to one where patient autonomy dictates all medical choices of the physician. The former makes the physician a god, the latter, a technician. Neither is right, but concerns abound that the latter model is becoming the norm in modern medicine. He writes:

“All-out treatment, we tell the incurably ill, is a train you can get off any time—just say when. But for most we ask too much. They remain riven by doubt and fear and desperation; some are deluded by a fantasy of what science can achieve. Our responsibility, in medicine, is to deal with human beings as they are. People die only once. They have no experience to draw on. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come—and escape a warehoused oblivion that few really want.”

The nature of such conversations, those that we should all have with our families, that physicians should have whenever they provide a difficult diagnosis, complete Gawande’s analysis. The goals that people have for their lives, how intensely they feel they must continue a life that may be devoid of what they consider most important, must be discussed by physicians who see care for their patients as more than fixing an emergent problem to keep them alive. It is a treatise against a paradigm of vitalism, one that would declare that life must be sustained at all costs.

Gawande has written a commendable work, one that would benefit everyone from healthcare professionals, to those imminently facing their own mortality, to the generation who will be part of making decisions for aging family members. His prose is elegant and engaging, full of facts but rich in narrative that makes it very readable, even as difficult subjects are broached. The reader can be brought to tears from the emotional intensity of those it chronicles, yet called to action within a caregiving system that is rapidly improving but still has much work to do.

The author was raised Hindu, but has essentially renounced that religious system. It is unclear that any other religious system has supplanted it in his life. Despite the substantial wisdom that the book imparts, Evangelicals will likely find a vexing lack of the transcendent in the conclusions Gawande reaches. While he is not antithetical to religious faith, rather linking it in with other activities that the elderly find significant, like playing bridge or eating chocolate ice cream, he certainly does not dwell on the vital role faith can play in the lies of the dying. The reader must look elsewhere for this discussion.

He does reflect on the bioethical principle of autonomy as distinct from living a life of complete independence, “free of coercion and limitation.” In his view, a more compelling sense of autonomy lies in the ability “to be the authors of our own lives.” This is, in a sense, a very human need, one with which we can all identify. But the Christian life is one marked by the gradual death to self that leads to true life, so that Paul could declare, “To live is Christ and to die is to gain.” We are ultimately confronted with the life of the cross, one that places our worth within the story of God, not ourselves. God is our author, though Jesus Christ, and our hope lies in the role we play in His grand narrative. Gawande’s analysis is not so much incorrect as it is lacking. We crave eternal meaning that only God can give, and we are weak authors of even our own stories within this much larger one.

The ears of Evangelical bioethicists will be pricked as Gawande broaches the subjects of euthanasia and physician-assisted suicide. While I am not in agreement with his view that physicians should have the ability to prescribe drugs to allow the terminally-ill to end their own lives, within a tepid acknowledgement that these pills can offer some peace and comfort to the dying, who rarely use them, he makes it clear he does not see a role for euthanasia in medicine. In fact, he reports the quality of hospice and palliative care in the Netherlands, the prototype nation for euthanasia policies, is notably inferior to that of the United States. It would be nice to see a stronger analysis of why such policies are antithetical to the practice of medicine, but perhaps that is asking too much from an author without an explicit theological conviction to express. Frankly, I had far greater worries that, in a secular book, an even-handed response to the excesses of “live-at-all-costs” he decries would be achieved at all.

With these criticisms aside, Atul Gawande has succeeded in writing a book that is highly readable and richly applicable to physicians, ethicists, and those who must face the difficult realities of our own mortality. It is not Christian, to be sure, and is therefore incomplete in how Christian believers would view mortality, but the wisdom he presents has great application (with a few exceptions) within an Evangelical ethic. As society works to erode a sense of our own mortality, Dr. Gawande has authored a must-read analysis of how we must rethink that paradigm.